Obvious
by Allura99
Summary: House and his team get a case of a young doctor. Can they figure out her disease? What is the missing piece of this particular puzzle?


Obvious

A House Fanfic

Dr. Theresa Pernell was grateful to find a relatively empty corner of the nurses' station. She placed her armful of charts on the counter and sank into the chair. 'So far, so good,' she thought as she logged into the computer.

The holidays were always maddening around the hospital. Half of the medicine residents were off for Christmas while the rest would be off for New Year's. Many of the other services, such as neurology, did the same. Staff was at bare bones. You didn't even dream of doing an elective CT at this time of year.

As Theresa had elected to work Christmas this year, her intern was off. Though his replacement did not know the patients well, she was handling the situation well. Theresa made a note to pass along that observation to the chief residents and the attending.

'Just a few more days,' Theresa reminded herself as the computer finally finished its warm-up routine. 'Then I get to escape for a few days.'

She quickly reviewed the lab results and radiology reports for all her patients. Mrs. Mayers would need oral potassium replacement. She dreaded calling radiology to arrange for the CT to further evaluate Mr. Donaldson's possible small bowel obstruction. She wrote orders as she reviewed the data, hoping the extra efficiency would let her and the intern leave a bit sooner today.

So absorbed in her work, Theresa was startled when the intern took the chair beside her. Anne murmured an apology before starting on her own stack of charts. Theresa waved the apology aside, saying something about too much coffee.

"By the way," Anne said, "I finally managed to get Mr. Claricluzio's family to agree to come get him. It took me thirty minutes to convince them that I really couldn't justify an ambulance taking him back home. They'll be here at noon."

Theresa frowned. "You really should let the social worker handle things like that. It's her job."

"Well, usually I would," Anne stated, "but she's busy trying to find nursing home placement for Mrs. Washington. You know what a nightmare that can be. Dealing with the Claricluzio family seemed the lesser evil."

"True," Theresa agreed. She scratched her arm for a moment before becoming aware of the raised area of skin. Feeling dread, she pushed the sleeve back. There on her forearm was a red, raised area nearly the size of a quarter. "Great, just great."

"Something wrong?"

"I have to go to employee health," Theresa said as she rose from the chair. "It shouldn't take long. If you have any questions while I'm gone, just page me."

"Sure thing. Are you okay?"

"I'm fine. Like I said, this shouldn't take long."

"So, what do we got?" House asked as he limped into the workroom.

"Dr. Theresa Pernell," Cameron began, flipping through a relatively thin chart, "age twenty-eight and a senior internal medicine resident here. No known medical problems. She went to employee health this morning where she became irate, repeatedly demanding to see a staff physician and to get a chest x-ray."

"Interesting demand," House mused. "And where is the good Dr. Pernell now?"

"Heavily sedated in the ER," Chase supplied. "The nurse called security when she wouldn't leave quietly."

"And I take it that this is not typical behavior for her."

"Not at all," Cameron said. "Her employment record here is clean. She has actually gotten several complements from the families of her patients."

"She was one of the favorites in her class to become a chief resident," Foreman added.

House limped over to the wipe board. "Level-headed senior resident becomes irate in employee health, demanding to see a staff physician and to get a chest x-ray. Thoughts?"

"Drugs," Chase said, earning glares from Cameron and Foreman. "What? She's a resident working hellish hours, especially during the holidays. Amphetamines and other stimulants can cause irrational behavior."

"Okay, so we have drugs on the table," House said. "Anything else?"

"Acute psychotic break," Cameron said.

"Psychosis?" Chase scoffed. "You laugh at drugs but immediately go for a psych diagnosis?"

"She is in the right age group," Cameron countered, "and the stress of residency could be enough to trigger an episode."

"But there's no previous history of unusual behavior," House said. "And I'm willing to bet there's no family history of mental illness either. Crazy people, particularly schizophrenics, just don't get into medical school, you know."

Foreman found the attention shifted to him. "Fine," he muttered, "vasculitis."

"Oh, lupus," House said, rolling his eyes, "as if you haven't thrown that one out there before. But throw it enough times, and it's bound to stick, right, Foreman?"

"You asked for ideas," Foreman said. "That's an idea. She's young and female. Autoimmune disorders aren't unheard of in her age group."

House reviewed the board. "Fine, so we have drugs, psychosis, and lupus. Chase, get her admitted and get going on the tox screens. Cameron, get her mother on the phone and get a detailed family history. Foreman, you have the autoimmune work-up. And why don't you add a head CT while you're at it, just in case she has a mass up there. I'd hate for us to miss brain cancer."

His minions quickly scurried out to get started on their tasks. House picked up Pernell's file and began to flip through it himself. He couldn't shake the feeling he was missing something.

Theresa went to rub her eyes and found she couldn't raise her wrists. The same went for her ankles. "What the hell is going on here?"

"You're in the hospital," Chase said, pushing another tube into the vaccutainer hub.

"Who are you and why am I restrained?"

"I'm Dr. Chase, and they called a 'code white' on you in employee health. Two cops had to hold you while the nurse gave you the Ativan."

'Code white' was when a person was threatening to become violent. It was frequently used for psychotic patients on the psych wards. Anger and embarrassment flared through her. The nurses had used it on her.

"I wasn't becoming violent," Theresa said, trying to keep her voice calm. "I just wanted to see one of the staff docs to look at my arm and to order a chest x-ray. When the nurse said there wasn't a doctor today and refused to let me know when there would be one, I lost my temper. I don't have time to be stuck in the ER. I have a service to run.

"Oh, God, my service. Please, someone has to tell my intern where I am. And I need to get David or somebody to cover my patients. Anne's good but she can't handle everything on her own."

"Already taken care of," Chase assured her. "Now, just how badly did you lose your temper?"

"I merely raised my voice and told her that this was unacceptable. When I turned to leave, there were two cops at the door who grabbed me. I was trying to get them off of me when the nurse hit me with the shot."

"You were mumbling incoherently when you were brought down to the ER. It seemed best to have you restrained."

"Let's see how coherent you are when you're slugged full of benzos." She squirmed in the restraints. "Can I please get out of these things? I'm perfectly rational and slowly itching to death."

"Itching?"

"Yeah, all over."

Chase jerked the sheet back. Her skin was breaking out into hives. She then started wheezing. Chase watched in horror was her oxygen saturation began to drop.

"Epi," she rasped. "Get me some epi!"

She watched Chase rush out of the room before she lost consciousness.

"So, now instead of being restrained and sedated, our resident is now intubated and sedated."

Chase nodded. "Textbook anaphylaxis reaction."

"Except for the time frame," Foreman countered. "She got that dose of Ativan hours ago."

"Some people do not develop anaphylaxis until hours after an exposure."

"Some, but not many," House pointed out. "Could this be something else?"

"She said that she was going to have the doctor look a spot on her arm when she went to employee health."

"And did you get a look at this spot?" House asked.

"No, she was already developing hives."

"But you're sure she said spot and not spots."

"Yes."

"Is that important?" Cameron asked, glancing from Chase to House.

House shrugged. "I don't know. Could be."

"Just so you know, her tox screens were negative except for benzodiazepines."

"Which was kindly administered by Nurse Overreaction in employee health. So drugs are out." House turned to Cameron. "What about the history?"

"Only positive for bipolar disorder in a maternal uncle. No history of schizophrenia or other mental illness. No one has been institutionalized. And the mother denies any history of bizarre or irrational behavior in Dr. Pernell."

"Which takes care of psychosis, especially since she was lucid with Chase despite the Ativan hangover before going into shock." He turned to Foreman. "Your turn."

"ANCA was positive while her sed rate and CRP are elevated."

"So she has non-specific autoimmune marker positive and some elevated inflammatory markers. I take it that you already have the next phase of the work-up going."

Foreman nodded. "Her CT head was negative but we got a few slices of her lungs in the scan that were interesting."

"How interesting?"

"Got some kind of lesion in the left apex. Radiology couldn't be more specific on just a few slices."

"Get a CT chest, abdomen and pelvis with contrast," House ordered as he limped out of the room. "Find out what this lesion is."

"Where are you going?" Cameron asked.

"Lunch."

Cameron stared at him in disbelief. Lunch? Now?

Forearm touched her arm, getting her attention. "Come on, we've got work to do."

"What do you want?"

"Now, Wilson, is that any way to greet someone?" House chided.

"It is if it's you," Wilson replied. "What do you want, House?"

"Well, I need to discuss a case with you," House said as he got in line behind his friend.

"Hey!" the guy behind Wilson protested.

"Sorry, cripple affirmative action." He turned back to Wilson. "Anyway, I've got this patient who had an anaphylaxis reaction to Ativan today."

"Sounds like you need to be talking to an allergist, not an oncologist. Say, isn't one of your fellows an immunologist?"

"Cameron lacks your manly insight." He ignored the death glares of the guy behind him as he piled his tray with food. "Besides I need someone with new ideas."

"Does your patient even have cancer?" Wilson demanded as he went up to the cashier.

"Not that I know of." He smiled at the cashier. "We're together."

Wilson rolled his eyes but paid. "Then I don't know what good I'll do for you."

"Well, you at least bought me lunch."

Wilson shot him a glare before walking off toward an empty table.

"There you are," Cuddy announced. "You were supposed to be in clinic two hours ago."

"But Dr. Cuddy, it's nearly Christmas."

"So quit being a Scrooge and go see your patients." She waited a moment but House made no move to get out of his chair. "Or should I add more clinic hours?"

"Bah, humbug," House muttered, reaching for his cane. He didn't miss Cuddy's smirk as he made his way to clinic.

His first patient was neurotic old lady. She concerned about a pea-sized lump in her bottom. "Hemorrhoid. Try some ointment."

"But it's inside me."

House studied the lady with new interest. "And just how did you notice that?"

"Well, I check everything down there."

"I see." House got to his feet. "I'll be right back."

"Oh. Okay."

As he had hoped, Chase was at the nurses' station. "Patient in exam 3 needs your special touch."

"Really?" Chase said, taking the chart. "Thanks."

House chuckled as he watched Chase go into the exam room. 'Sucker,' he thought. He quickly took the next chart while Chase remained occupied.

A nice middle-aged woman sat on the exam table. "Hello."

"Hi, I'm Dr. House." He sat on the stool. "What brings you in today?"

"Well, I have an infection in my arm," the woman said, pulling up her sleeve. "I thought at first it was a spider bite but then I realize that's where I test."

House looked up from the abscess. "Test?"

"Test my blood sugar," the woman explained, "for my diabetes. I have one of those meters that uses blood from your forearm instead of your finger."

"It's where you test," House murmured. "On your forearm."

"Um, yeah?"

"You're right," he said, smiling at her. "It's an infection. I'll have someone come drain it and give you some antibiotics."

The woman watched as House went to the door. "You're not going to do it?"

"Sorry, no. I have another patient to see to."

Chase was the last one to arrive. "Sorry I'm late. I was finishing that rectal exam you left me."

"Well, I did say she needed your special touch."

"House!" Cameron cried. However, her boss looked unrepentant. She sighed. "Where's Forearm?"

"He'll be here in a bit," House said. "I asked him to stop by radiology on his way here."

He gestured to the board. "Now back to our really sick patient. What happened to her at employee health this morning?"

"She became unruly to the point that she to be sedated," Cameron said.

Chase nodded. "And she developed anaphylaxis from the Ativan."

"But why did she go to employee health?" Both Chase and Cameron gave him blank looks. "Exactly. We've been so focused on what happened to her there and since then that we forgot why she went there in the first place."

He tossed a file at Cameron. "The chart you had was incomplete. Here is the file on her from employee health. Dr. Pernell asked to have a PPD placed two days ago but she wasn't due to have one until April. Why would she choose to have it early?"

"Because she was going to be on vacation?" Chase guessed.

"No," Cameron said. "She may have been having symptoms of TB: night sweats, weight loss or something else. She went to get tested."

Foreman entered. "I got your CT results."

"Let me guess," Chase announced, "consistent with pulmonary TB."

"Exactly."

"Put her on respiratory isolation and start her on four drug therapy," House ordered. "Someone will need to alert the health department."

"So, TB, huh?" Wilson said, handing House a beer. "Sometimes we miss the obvious. It happens."

"Not to me."

Wilson gave him an affectionate smile. "It merely proves that you, too, are human, House."

"Save it for the new nurse on 3 North."

"She is cuter than you."

"So, you have noticed."

"Apparently so have you."

House smirked. "With those scrubs, it would be hard not to."

Author's Note:

First, I'm a fan of House. I have been since the beginning. But I sometimes get frustrated with how medicine and its practice is portrayed on the show.

One of the most repeated rules in medicine is that a good history and physical will lead you to the diagnosis 90 of the time. Ideally you should use tests to confirm your diagnosis. In the show, House routinely orders tests without even laying eyes on the patient. In this story, if he had examined the patient, he would have put her exam along with the history Cameron gave and made the diagnosis.

Another thing that bothers me is the formulaic setup of the show. I use to joke with my friends that if I was one of House's patients I would hope they would find the diagnosis before I coded three times. After all, those paddles hurt.

And the shotgun approach ("let's throw everything at him and hope it works") that is used in the show just sets my teeth on edge. Yes, it is used in the real world but only in times of desperation. A more orderly approach is always best. In medicine, the wrong treatment can have horrible consequences.

The whole thing where Theresa was sedated was a slight towards a few nurses I have worked with. Anytime a patient argues with them or doesn't do exactly what they want, they're calling for the patient to be sedated, restrained, or both. Now, don't get me wrong. There are times when this is appropriate and these nurses are only a few. But I couldn't help putting the jab in here.

Finally, I based the operations of the employee health clinic largely on how it is done in the hospital where I work. I'm sure there are better run ones out there. This is just the set-up I'm familiar with.

As for the cases presented here, they are similar to ones that I have encountered in real life in some way. However, no one patient completely corresponds to one I have encountered. Names have been changed as well.

Please don't take any medical lessons from this. If you're sick, please go see a doctor.

Hopefully, you won't need a House.


End file.
